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Monday, 21 November 2011

Learning from other industries is important,
airlines and pilots have been the common sources for healthcare; the oil
industry, especially SHELL is also a very good source.

THE CHALLENGE THROWN TO HEALTHCARE

The oil company SHELL has an extremely high
priority for safety. When SHELL do any construction work the area is marked
'This is a safe work place'. It is not a warning or an
advisory, it is a statement. At the International Forum for Quality and Safety
in Healthcare at Amsterdam in 2011, the question and the challenge that was
posed was, which hospital actually has a sign that says 'this is a safe
hospital' and which hospitals are working towards that explicit
goal?

That is very interesting. Would it be possible
to guarantee safety in healthcare? As an enthusiast I would argue that it would
be possible in many areas, well at least in some areas, but as a realist I know
it would be difficult.

Mr. Rein Willems was the Chairman of SHELL
and is now a member of the upper house in Netherlands. He has authored the brief
but powerful report which is now the basis of improving safety and quality of
healthcare in Netherlands. He spoke at the Forum in Amsterdam. I share some of
the messages here.

RED LINES AND DISCIPLINE

In Shell, the by-line for 'this is a
safe work place' is ''here you work safely or you don't work
here at all''. Willems said that there was an occasion when
a worker despite adequate warning and training persisted in the unsafe practise
of smoking in a non-smoking zone in a production site and the CEO physically
escorted that employee out of the premises and the employee was sacked on the
spot.

Though it is a dramatic example it illustrates
the seriousness with which safety is taken in Shell. What is our equivalent
example in healthcare? We may do that for fraud or for smoking near the oxygen
tanks – those are important but are general to any facility – what is the
example that relates to clinical care delivery?

MANAGING VERSUS SOLVING

Willems went on to use the iceberg analogy that
for every single fatality there were 50s of 'lost time accidents', 100s of
property damage or minor injury, 1000s of accidents/incidents with no injury and
10000s of small events/breaches. To avoid that single fatality the underlying
causes of 'small incidents' have to be fixed. Managing small events without
fixing the underlying causes will eventually escalate into major problems.

In healthcare we are very good at
emphasising on 'risk management'. As far as I am aware risk management is about
identifying and understanding risks and minimising them. Which is at least a bit
different from enhancing safety – which is about continuously increasing the
standard of practice to the best that is currently possible. In terms of
quality, risk management could probably equate to the principle of quality
control by checking the products. Safety in healthcare would probably be the
equivalent of getting it right as we go along. There lies the
difference.

Having said that, it is possible that some of
the people who are currently doing governance and risk are also doing safety;
hats off to them since they have to cope with varying threads within a concept.
I suspect most people may not be doing this.

EVERYONE DOING THE SAME THING

Willems also touched on the concept of
uniformity of shared practices. In Shell they have a policy where 'all employees
should have one hand on the stair rail when they are going up or down stairs'
this was implemented in their sites (oil fields and refineries). On one occasion
Willem and his CEO were photographed in the head office walking the stairs with
papers in hand without holding the side-rails. An employee wrote to Willem
querying if the rule applied only to lower level staff. With a view to leading
by example and with a view to having similar rules for everyone in Shell it is
now the policy that whether one is on the field/rig/factory sites or in offices
that one hand must be on the rails while going up or down
stairs.

We in healthcare are no SHELL but to be fair I have
seen a senior board director removing her jewellery before entering a ward, though she was there for administrative reasons.
That is a good sign.

I think the core idea was that senior
leadership has to play a very visible, proactive and hands-on role in the area
of shared baselines, analysing data, resolving issues and safety. These concepts
are essential for safe healthcare but are not often done in comprehensive or
meaningful ways; that is what we ought to get right.

Shell and Willems do have generic lessons for
us in healthcare.

HEMADRI

NOTE: The writing in italics are my personal
views. The normal type is what Mr Willems said or his views.

Thursday, 3 November 2011

Candour is the quality of being honest and
telling the truth, especially about a difficult or embarrassing subject[1]. When things go wrong and especially when patients are harmed
whether it is due to natural circumstances or due to error by individuals or
systems candour becomes very important. One of the components of such candour
is to offer an apology to the patients and their families. It is important to
understand that as clinicians we may not be apologise for in a ‘conventional’
sense when there is no individual error is involved; what we would be
apologising for in all cases is for the fact that the patients’ expectations
were unable to be fulfilled on that occasion.

Compensation Act 2006 states: ‘An apology, offer of
treatment or other redress shall not of itself amount to an omission of
negligence or breach of statutory duty. The medical indemnity providers have
always held a similar view that apologising does not put a clinician at risk of
being accused of anything in the future – it is not an admission of liability.

In the document ‘The Coalition: our
programme for government’[2] it says "We will enable patients to rate hospitals and
doctors according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell
patients if something has gone wrong". The words ‘will’, ‘require’
and ‘always’ seems to indicate that the government is inclined towards
introducing statutory candour or some
version of it.

The CMO has been recommending a statutory duty of candour
for a good few years and there are currently deliberations including the GMC on
this subject. There has been parliamentary health select committee
recommendation to consider this subject.

Understandably patient groups especially the AvMA are in
full support of a legal duty of candour; understandable because of the powerful
case studies[3]
they use where a statutory duty could have either avoided prolonged and
vexatious interactions with authorities involved in those case studies or would
have helped to bring events to a closure quickly.

The MDU does not support the consideration of a statutory
duty of candour based on the argument that there is already an ethical duty
backed up by adequate GMC sanctions.[4] The MPS
also seems to take a similar view. The NPSA’s new ‘being open’ policy (as
opposed to its ‘open disclosure’ policy) is based on the premise that doctors
apologising would prevent many unnecessary complaints and possibly some of the
litigation that follows. There is international evidence that litigation occurs
less often when an apology is offered and accepted upfront.

The GMC guidance on good medical practice[5] states
‘‘if a patient under your care has suffered harm or distress, you must act
immediately to put matters right, if that is possible. You should offer an
apology and explain fully and promptly to the patient what has happened and the
likely short-term and long-term effects’’. However, a 2008 survey by the
MPS[6] showed
that while more than 90% of professionals believed that patients are less
likely to litigate after errors if they received an explanation and an apology
but only 68% were willing to be open when something went wrong. Clearly the
issue of liability and blame still plays in the minds of doctors.

This raises the question whether the duty of candour should
be statutory or mandatory.

Clinicians especially doctors really would not want
statutory duty of candour as they would like to think that they are doing the
right thing because it is the right thing and not because it is simply required
by law. The GMC and other bodies, regulatory or not, take a very poor view of
lack of transparency. Actioning after an event of low transparency is
like many other triggers may turn out to be subjective, discretionary and inconsistent. However, in practice once the issue reaches the 'authorities' there are significant consequences which inevitably follow. Therefore a culture
change route is preferable for clinicians.

The next issue to consider is how we design a
response to the call of ‘duty of candour’. What the profession needs to
understand is whether there was a rising trend that doctors and other
clinicians are getting less transparent, if there is no such trend whether
there are frequent examples of lack of candour. There seems to be no general
trend that doctors are getting less transparent. Hence, a culture change
approach using the voluntary duty supported by a strong view from the GMC and
other bodies would certainly make a difference from the perspective of clinical
professionals; with aberrant doctors dealt with strongly by using the full
force of current systems.

There are however, very frequent examples of outliers.
This is when we have to recognise that institutional candour is a different
situation. While individuals are all for openness, the current system of
risk, clinical governance, complaints and legal actions inevitably raises
doubts on the relevance of the extent of candour and its impact on future
action against organisations. Further, often in inefficient and overspent
circumstances or in situations of poor organisational vision, what is not
required by the force of law or the force of higher authority is actively
prevented from happening. This is understandable from an organisation's
perspective but would be unacceptable to patients. There are examples of
individual clinical candour followed by organisational resistance that happen
in sequence. This is obviously unsatisfactory.

On balance, it seems that under current moral mores
of our society a statutory duty of candour is probably going to be
inevitable. The question is of course is
whether individual clinicians or the organisation would be legally responsible
for the statutory duty of candour. It would make sense for the organisation to
be responsible for such a statutory duty. The issue of candour after serious
untoward incidents has extremely personal and wide ramifications at the same
time, that it becomes clearly outside the remit of individual personal clinical
responsibility. Further, organisations and organisational responsibility is
likely to cover everyone in the organisation which would include doctors - any
aberrations on the grounds of candour by doctors would therefore be dealt with
by their organisation and by the GMC.

There might be a case for parallel dual responsibility (which has the risk of diluting responsibility) or for purely individual responsibility (where it could become 'fault', 'witch-hunt' and 'scape goating' usual suspects). In a broad sense since the responsibility
for quality moved from consultants to chief executives in the mid 80s, candour
as such should therefore be an organisational responsibility delivered by
individuals rather than individual responsibility enforced by personally
applicable law.